Ob-Gyn Coding Alert

Given a description of the -22 modifier, it may appear to be an easy ticket for getting more money when a procedure requires extra work. But according to Janet McDiarmid, CMM, CPC, MPC, president of the American Academy of Professional Coders, this modifier needs to be used with caution and is often considered by payers to be over used. The CPT states the -22 modifier is to be used when the service(s) provided is greater than that usually required for the listed procedure. The following tips will help the coder use this modifier correctly and in the appropriate circumstances.

1) Time Spent Not Exclusive Factor.

In most circumstances, when a procedure involves more work, it also involves more time. But the amount of work, not the amount of time, is the appropriate doorway to using the -22 modifier correctly. According to McDiarmid, many people mistakenly think the -22 modifier is just about more time. Time is not involved, she explains. Significantly more work must be involved in the procedure -- a lot of extra work. Just because a procedure takes more time than usual is not enough justification. You must be able to describe the extra work involved.

Adelia Cooley, billing education audit manager, Oakwood Ambulatory Administration, Deerborn, MI, says that a common ob/gyn example of correctly using the -22 modifier is the abdominal hysterectomy that involves extensive lysis of adhesions. The operative report needs to reflect the extensive work involved, and not just that it took more than the usual amount of time. In the case of the TAH (through the abdomen hysterectomy), if the physician has spent several hours working through peritoneal adhesions that were both dense and vascular and required careful and involved work, then the procedure would qualify for the -22 modifier. According to McDiarmid, just saying it took more time is not enough. In addition to just requiring extra work, the situation must be unusual for the physician to justify this modifiers usage. If the ob/gyn is accustomed to doing these difficult cases and this is the norm for his work, the modifier -22 cannot be used.

Note: The -22 modifier should not be confused with the -25 modifier. While both provide for reporting additional services preformed, the -25 modifier is only to accompany Evaluation and Management Service codes and the -22 modifier is only used with codes from the surgical section of the CPT.

2) Miscellaneous Uses.

The -22 modifier may be used to explain extra procedures that included additional components that are not codable separately (do not have their own CPT codes). An example could be a marsupialization of Bartholins gland cyst (56440) that also included a Bartholins gland resection. The -22 modifier would be attached to 56440 because there is not a code for the resection. A -22 could also be used with code 56515 when lesions are destroyed on the vulva and involve an area that is equivalent to a vulvectomy (but you cant use the vulvectomy code because it is for excision, and what you did was laser destruction). Finally, a -22 could also be used when you do more that one major procedure through a laparoscope. For instance, fulguration of endometrial implants along with lysis of extensive pelvic adhesions.

3) Always Include a Report.

I always send an operative report to the payor when I use the -22, says Joan Dent, patient account supervisor, Turning Pointe Womens Health Professionals of Akron, OH. Reports should clearly demonstrate in detail why extra work was needed, what exactly was done, and the extra amount of time this work involved.

4) Billing Tips.

In addition to the tips above, Thomas Kent, CMM, business administrator, OB &GYN of St. Marys, Leonardtown, MD suggests the following billing tips for the submission of the claim utilizing modifier -22:

A) When using this modifier you will probably want to increase your fee for the services -- to account for the additional amount of work done. How much you increase your fee will depend on how much extra work was done. Some practices simply increase it by 150%. However, insurance companies usually respond better when the extra work can be compared to another procedure for which they have an established fee. For instance, in the example above, the destruction of the vulvar lesions might have been compared to the work that would have been performed with a partial vulvectomy. The fee charged by the physician would then be set at the level for the vulvectomy, with this explanation accompanying the claim.

B) The exception to the tip about sending operative reports and documentation stated above is in the submission of the electronic Medicare claim. Go ahead and immediately submit the claim with good diagnostic support. Some carriers will simply call for the explanation. Others will reject the extra fee but pay the normal rate. This brings you some immediate cash flow, and then you can send an appeal with the documentation for the extra fee to be sent later.

C) Create a cover letter which describes in simple terms the extra effort required in this operative session. This will help the claim receive faster processing.